| RPT |
.|.|Clinical Institute Withdrawal Assessment - Alcohol Revised||Date Given: <.Date_Given.>|Clinician: <.Staff_Ordered_By.>|Location: <.Location.>||Veteran: <.Patient_Name_Last_First.>|SSN:
<*Answer_4874*>|11. HEADACHE, FULLNESS IN HEAD - Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise,
rate severity:| <*Answer_4875*>|12. AGITATION - Observation:| <*Answer_4876*>|13. ORIENTATION AND CLOUDING OF SENSORIUM - Ask, "What day is this? Where are you? Who am I?"|
<*Answer_4877*>|||Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for
accuracy and used in conjunction with other diagnostic activities and procedures.| $~
<.Patient_SSN.>|DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)|Gender: <.Patient_Gender.>||CIWA-AR| Total Score: <-Total Score->||Scores of less than 8 to 10 indicate minimal to mild withdrawal.
|Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal).|Scores of 15 or more indicate severe withdrawal (impending delirium tremens). ||Questions and Answers||1. Time (use 24 hour
clock, midnight is 00:00):| <*Answer_4865*>|2. Pulse or heart rate (taken for one minute):| <*Answer_4866*>|3. Blood pressure:| <*Answer_4867*>|4. NAUSEA AND VOMITING - Ask, "Do you feel
sick to your stomach? Have you vomited?" Observation:| <*Answer_4868*>|5. TACTILE DISTURBANCES - Ask, "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel
bugs crawling on or under your skin?" Observation:| <*Answer_4869*>|6. TREMOR - Arms extended and fingers spread apart. Observation:| <*Answer_4870*>|7. AUDITORY DISTURBANCES - Ask, "Are you
more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation: |
<*Answer_4871*>|8. PAROXYSMAL SWEATS - Observation:| <*Answer_4872*>|9. VISUAL DISTURBANCES - Ask, "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you
seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation: | <*Answer_4873*>|10. ANXIETY - Ask, "Do you feel nervous?" Observation:|
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